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PubMed2003

A practical method of linking data from Medicare claims and a comprehensive electronic medical records system.

BACKGROUND: Linking administrative and clinical databases provides opportunities for richer studies to improve healthcare, but linkage may require sophisticated algorithms. Linking US Medicare data with large databases used for everyday clinical practice is seldom described in detail in medical literature. OBJECTIVES: Test a deterministic method of linking data from a local electronic medical records system to Medicare data, and report specific details of the algorithm used as well as lessons learned from the linkage process. SUBJECTS: Medicare beneficiaries with medical encounters in selected Indiana counties in the 5-year period ending in 1999. RESULTS: For 6,388 beneficiaries with Medicare data indicating inpatient encounters in the system, 98% had links to the clinical database. Of 7,231 patients hospitalized and registered in the local clinical system, 86% contained a link to Medicare data, and 69% contained a link even without using Social security number (SSN) as an identifier. Medicare data that conflicted with local hospital records by indicating no local hospitalization occurred in 1.8%. More than 2,000 claims contained hospital identifiers that did not exist in the hospital codebook. CONCLUSIONS: Details of a practical, deterministic method of linking Medicare claims to a large electronic records system have been applied and described. Most records were linked without SSN. A variety of inconsistencies were found and these, along with missing or incomplete data, can influence linking. Integrity of specific variables must be assessed carefully.

Aged↗
PubMed2006

Cellulitis incidence in a defined population.

A population-based insurance claims database was used to examine cellulitis incidence, anatomical sites of infection, complicating diagnoses, source of health service, and recurrence rates. Insurance claim files were searched for cellulitis ICD-9-CM codes 681.0-682.9. Complications of cellulitis including erysipelas, lymphadenitis, lymphangitis, and necrotizing fasciitis were also identified by ICD-9-CM codes. We found a cellulitis incidence rate of 24.6/1000 person-years, with a higher incidence among males and individuals aged 45-64 years. The most common site of infection was the lower extremity (39.9%). The majority of patients were seen in an outpatient setting (73.8%), and most (82.0%) had only one episode of cellulitis during the 5-year period studied. There was a very low incidence of cellulitis complications, including necrotizing fasciitis. Cellulitis is fairly common, usually treated in outpatient settings, and is infrequently complicated by erysipelas, lymphadenitis, lymphangitis, or necrotizing fasciitis.

Adolescent↗
PubMed2002

Violations of service fairness and legal ramifications: the case of the managed care industry.

Adapted from Chan's (2000) model depicting success of litigation, this paper argues that with the application of various legislation, health maintenance organizations' (HMOs') violations of service fairness to each group: enrollees, physicians, and hospitals give rise to each group's lawsuits against the HMOs. Various authors (Bowen et al., 1999; Seiders and Berry, 1998) indicate that justice concepts such as distributive, procedural, and interactional justice can be applied to the area of service fairness. The violation of these underlying justice principles with HMOs' service unfairness to enrollees, physicians, and hospitals is examined. A general synopsis of the ethical issues in the managed care industry is provided. The various lawsuits launched by each group: enrollees, physicians, and hospitals together with the key statutes used are discussed. This paper also highlights the provisions and ramifications of the 11 April 2000 landmark agreement that Aetna made with Texas Attorney General John Cornyn to settle the 1998 lawsuit brought against the company. Lastly, the current ethical issues in the managed care industry are further discussed. The value of this paper can be adapted to the study of organizations' service fairness violations in other industries or in the educational, governmental, and not-for-profit sectors both nationally and internationally.

Conflict of Interest↗
PubMed2000

Reliability of Medicaid claims files for use in psychiatric diagnoses and service delivery.

To investigate the reliability of Medicaid claims data for use in research, clinical decision-making, and policy, medical records were abstracted of 105 inpatient stays on the psychiatric service of a large general hospital. Primary and secondary diagnoses and outpatient specialty mental health services after hospitalization were compared between Medicaid claims data and medical record information. Primary and secondary diagnoses were reliable, but claims data failed to capture several types of outpatient services. This suggests strategies to use claims files more appropriately.

Humans↗
PubMed2004

Cost of illness associated with metastatic breast cancer.

This study assesses cost of illness of metastatic breast cancer (MBC) patients over a specific period of time as observed in Medicare program expenditure data. Incident cases of MBC from 1997 to 1999 were included. Direct care cost data were obtained from Medicare claims from a 5% national sample of program beneficiaries. Costs to the health care system were determined from the date of first diagnosis of MBC to the end of follow-up. A matched case-control study provided comparison of Medicare payments in cancer and non-cancer patients. A total of 397 MBC patients were identified and followed for an average of 16.2 months. The mean total cost was US$ 35,164 per MBC patient and US$ 4176 per person for the control group. Over the follow-up period, the MBC patients averaged 1.7 inpatient admissions per patient and 14.4 inpatient days per admission. The control group averaged 0.3 inpatient admissions per patient and 1.6 inpatient days per admission. Home health aide for MBC averaged one visit every 2 weeks. The direct costs for the older MBC patients were less than the direct costs of the younger MBC group. Multivariate regression analysis showed that as the age increased, the Medicare costs decreased within the MBC cohorts. Less combination treatments were provided for older MBC patients. Cost of illness was inversely proportional to age.

Aged↗
PubMed2002

Actual versus self-reported scholastic achievement of litigating postconcussion and severe closed head injury claimants.

Psychologists typically rely on patients' self-report of premorbid status in litigated settings. The authors examined the fidelity between self-reported and actual scholastic performance in litigating head injury claimants. The data indicated late postconcussion syndrome (LPCS) and severe closed head injury litigants retrospectively inflated scholastic performance to a greater degree than nonlitigating control groups. The LPCS group showed the highest magnitude of grade inflation, but discrepancy scores did not significantly correlate with a battery of malingering measures or with objective cerebral dysfunction. These findings support previous studies, which showed self-report is not a reliable basis for estimation of preinjury cognitive status. Retrospective inflation may represent a response shift bias shaped by an adversarial context rather than a form of malingering.

Adult↗
PubMed2000

The provision of primary care dental general anaesthesia and sedation in the north west region of England, 1996-1999.

AIM: To investigate trends in the provision of primary care dental general anaesthesia (DGA) and sedation following the new guidance from the General Dental Council. DESIGN: Cross-sectional analysis of data about the provision of DGA in the General Dental Service and Community Dental Service from 1996/97 to 1998/99. SETTING: The North West Health Region of England. METHOD: The numbers of DGAs in the General Dental Service (GDS) and Community Dental Service (CDS) for the three financial years, 1996/97, 1997/98 and 1998/99 were examined. In addition General Dental Service quarterly information about the numbers of general anaesthetics, sedations requiring another dentist or doctor, and claims for conscious sedation or inhalation sedation from April 1997 to December 1999 was requested from the Dental Practice Board. RESULTS: The numbers of DGAs declined by 24 per cent between 1996/97 and 1998/99. Those in the GDS fell from 14,550 in the first quarter of 1997/98 to 3,527 in the first quarter of 1999/2000. The number of claims for sedation, which required another dentist or doctor, increased from 712 in the first quarter of 1997/98 to 2,989 in the same quarter of 1999/2000, while the number of claims for conscious sedation and inhalation sedation increased slightly from 2,847 to 2,963 over the same period. CONCLUSIONS: The revised General Dental Council guidance has reduced the numbers of DGAs being carried out in both GDS and CDS. The number of sedations involving another dentist or doctor has increased considerably but the new guidance seems to have had little effect on the numbers of patients receiving operated administered conscious sedation and inhalation sedation.

Adolescent↗
PubMed2005

Measuring access to health services: General Dental Services in Scotland.

OBJECTIVE: Recently the issue of access to health services has been brought into sharp focus by clear evidence of rationing--patients queuing for NHS registration--in the NHS General Dental Services (GDS). Conventional estimates suggest that about 50% of adults are registered per annum. This paper demonstrates that these conventional measures of access and utilisation can generate potentially misleading inferences. DESIGN: By analysing individual-level claims data from over 35,000 patients over six years we are able to: identify the underlying patterns of utilisation that generate the aggregate 50% registration rate; provide more detailed estimates of utilisation and access; and suggest possible determinants of the patterns of utilisation we observe. SETTING: Primary care health services. RESULTS: In contrast to conventional estimates of access we find that close to 80% of the adult population in Scotland has had access to GDS over a six year period. Moreover, we find that the population is comprised of a relatively large group of patients (30% of the population) who access GDS at least once a year and a substantial group (19% of the adult population) who access services only once in six years. The groups who access services at intermediate frequencies are less numerous. CONCLUSIONS: Assessing the effectiveness of the public provision of health care services requires accurate information regarding access to those services. This paper sets out a framework for analysing and interpreting longitudinal data to provide information on the extent of access to health care services.

Adult↗
PubMed2001

The period prevalence and costs of treating nonmelanoma skin cancers in patients over 65 years of age covered by medicare.

BACKGROUND: Nonmelanoma skin cancer (NMSC) prevalence and treatment costs are rapidly increasing at an unknown rate. OBJECTIVE: To determine actual prevalence and treatment costs for NMSC in patients over 65 years of age covered by Medicare. METHODS: We used a 5% random sample of Medicare claims available for 1994 and 1995. Demographic characteristics, period prevalence, treatment types and frequencies, treating physician specialty, and allowable treatment charges associated with the diagnosis of NMSC were analyzed and described. RESULTS: More than 789,000 patients over age 65 covered by Medicare had a diagnosis and treatment for NMSC in 1995. Fifty-eight percent were men and 98% were Caucasian. The majority were from the South and West regions of the United States. Dermatologists treated more than 60% of these NMSCs. Treatment costs were approximately $285 million. The largest percentage of treatment expenditures (34%) was for excisions. CONCLUSION: The number of patients with NMSC is far greater than previous estimates. Dermatologists treat the majority of NMSCs. The mean treatment cost per patient is $329. Total expenditures for NMSC eradication represent 0.7% of the Medicare budget. NMSC is a major public health concern because of its increasing prevalence, costs, and the aging U.S. population.

Aged↗
PubMedDate not supplied

Comparing SSRI treatment costs for depression using retrospective claims data: the role of nonrandom selection and skewed data.

BACKGROUND AND OBJECTIVES: Since conventional randomized clinical trials often do not reflect the real world circumstances of prescribing behavior and patient outcomes, the use of retrospective administrative claims databases (RACD) has become more common in treatment cost comparisons among alternative pharmaceutical compounds. Several recent RACD studies have compared treatment costs for depressed patients prescribed SSRIs such as fluoxetine, sertraline and paroxetine. These cost comparisons have reached mixed conclusions. To begin to explain and reconcile the mixed SSRI cost comparison evidence, we undertake a variety of alternative multivariate analyses using a publicly available RACD. METHODS AND DATA: The 1995 to 1996 data encompasses a time period when all three SSRIs had become well-established agents. We report and compare results from multivariate linear regressions, logistic regressions, ordered probits and sample selectivity models, and examine robustness when adjustments are made for outlier observations and skewed distributions. RESULTS AND CONCLUSIONS: While choice of initial SSRI is nonrandom, the effect of sample selectivity on total depression-related and total health care expenditure is neutral across SSRIs. Although most cost measures are numerically greatest for fluoxetine, depression-related outpatient and hospitalization costs do not significantly differ by choice of initial SSRI. These findings are robust to alternative assumptions, specifications, and procedures. Antidepressant medication costs, however, are significantly higher when fluoxetine is the initial SSRI rather than sertraline or paroxetine, reflecting the larger proportion of fluoxetine patients prescribed a daily dosage of two or more capsules. Both total depression-related and total health care log-transformed costs are significantly lower for sertraline than fluoxetine.

Adult↗
PubMedDate not supplied

A checklist for retrospective database studies--report of the ISPOR Task Force on Retrospective Databases.

INTRODUCTION: Health-related retrospective databases, in particular claims databases, continue to be an important data source for outcomes research. However, retrospective databases pose a series of methodological challenges, some of which are unique to this data source. METHODS: In an effort to assist decision makers in evaluating the quality of published studies that use health-related retrospective databases, a checklist was developed that focuses on issues that are unique to database studies or are particularly problematic in database research. This checklist was developed primarily for the commonly used medical claims or encounter-based databases but could potentially be used to assess retrospective studies that employ other types of databases, such as disease registries and national survey data. RESULTS: Written in the form of 27 questions, the checklist can be used to guide decision makers as they consider the database, the study methodology, and the study conclusions. Checklist questions cover a wide range of issues, including relevance, reliability and validity, data linkages, eligibility determination, research design, treatment effects, sample selection, censoring, variable definitions, resource valuation, statistical analysis, generalizability, and data interpretation. CONCLUSIONS: For many of the questions, key references are provided as a resource for those who want to further examine a particular issue.

Data Interpretation, Statistical↗
PubMedDate not supplied

Long-term resource use and cost of percutaneous transluminal coronary angioplasty versus stenting in the elderly: a retrospective claims data analysis.

OBJECTIVE: Although the benefits of coronary stenting have been demonstrated in several large clinical trials, controversy remains as to whether stenting results in long-term cost savings compared to percutaneous transluminal coronary angioplasty (PTCA). The objective of this study was to evaluate the resource use and cost (Medicare payment) of PTCA versus bare stent in actual practice over a 2-year period. METHODS: The data for this study came from the 1996 through 1998 Standard Analytic Files that contain 5% of Medicare claims. The rates of repeat revascularization procedures and hospitalizations were reported at 1 and 2 years. Costs associated with inpatient admission, outpatient procedures, physician services, skilled nursing facility admissions, and home health-care services were included to perform a comprehensive assessment. Regression analysis was performed to test for cost differences controlling for case-mix variation between the patient groups. RESULTS: The selection process yielded 3782 PTCA patients and 2690 stent patients for analysis. The rate of revascularization was 26.7% for the PTCA group and 22.2% for the stent group at 2 years. The mean total cost for the initial procedure was 13,724 dollars for PTCA and 15,021 dollars for stenting. At 2 years, the total cumulative cost was 32,654 dollars for the PTCA group and 32,102 dollars for the stent group, a difference that was not statistically significant. CONCLUSION: Although the difference in the rate of repeat revascularization procedures between PTCA and stenting is not as large as those reported in clinical trials, bare stents are cost-neutral when compared to PTCA for the Medicare population.

Aftercare↗
PubMedDate not supplied

Defense of breast cancer malpractice claims.

The goal of this study was to determine whether factors associated with the successful defense and cost of malpractice cases involving the failure to diagnose breast cancer could be identified in medical and legal records. Secondary goals were to develop a multidisciplinary clinical algorithm utilizing National Comprehensive Cancer Network (NCCN) practice guidelines with practitioner risk management strategies. Physician deviations from these guidelines were tracked to identify high-risk areas in the diagnosis of breast cancer. A multidisciplinary clinical algorithm was introduced and practitioner risk management issues were addressed. In this study specific medical, legal, and cost factors were retrospectively abstracted and analyzed to identify associations between medical and legal factors and medicolegal outcome. ProMutual handled 156 malpractice cases involving breast cancer between January 22, 1986, and November 20, 1997. Of the total, 124 cases involving 212 defendants were closed. The closed cases were analyzed, using multivariable stepwise logistic and linear regression, to identify associations between clinical factors and case outcome. Women's health practitioners (WHPs), including obstetrician-gynecologists (OB-GYNs), family medicine, and internal medicine clinicians, were the largest group of defendants (97). Others included radiologists (43), surgeons (33), and pathologists (3). OB-GYNs accounted for 31% of these defendants, with a cost of more than $16 million. The greatest number of specialists represented in the open cases were radiologists, with 38% of the total. The defense model predicts that the probability of successful defense is lessened with inadequate record keeping, a patient that has metastasis and is alive, and a delay in diagnosis of 12 months or more. The overall indemnity model predicts a higher indemnity with the spread of disease at the time of evaluation, a patient who has metastasis and is alive, and a date of occurrence closer to the present. Indemnity is less in patients who have had a lymph node dissection, who have died, or who are alive without metastasis. The WHP model predicts an increased overall indemnity with the spread of disease at the time of evaluation and the presence of a mass without pain. Indemnity decreases with a history of pregnancy, absence of presenting symptoms, or presentation with pain with or without a mass, and the performance of a lymph node dissection.

Algorithms↗
PubMed2000

Why do physicians vary so widely in their referral rates?

OBJECTIVE: To determine which physician practice and psychological factors contribute to observed variation in primary care physicians' referral rates. DESIGN: Cross-sectional questionnaire-based survey and analysis of claims database. SETTING: A large managed care organization in the Rochester, NY, metropolitan area. PARTICIPANTS: Internists and family physicians. MEASUREMENTS AND MAIN RESULTS: Patient referral status (referred or not) was derived from the 1995 claims database of the managed care organization. The claims data were also used to generate a predicted risk of referral based on patient age, gender, and case mix. A physician survey completed by a sample of 182 of the physicians (66% of those eligible) included items on their practice and validated psychological scales on anxiety from uncertainty, risk aversiveness, fear of malpractice, satisfaction with practice, autonomous and controlled motivation for referrals and test ordering, and psycho-social beliefs. The relation between the risk of referral and the physician practice and psychological factors was examined using logistic regression. After adjustment for predicted risk of referral (case mix), patients were more likely to be referred if their physician was female, had more years in practice, was an internist, and used a narrower range of diagnoses (a higher Herfindahl index, also derived from the claims data). Of the psychological factors, only greater psychosocial orientation and malpractice fear was associated with greater likelihood of referral. When the physician practice factors were excluded from the analysis, risk aversion was positively associated with referral likelihood. CONCLUSIONS: Most of the explainable variation in referral likelihood was accounted for by patient and physician practice factors like case mix, physician gender, years in practice, specialty, and the Herfindahl index. Relatively little variation was explained by any of the examined physician psychological factors.

Adult↗
PubMed2000

Differences between generalists and specialists in characteristics of patients receiving gastrointestinal procedures.

BACKGROUND: As a result of market forces and maturing technology, generalists are currently providing services, such as colonoscopy, that in the past were deemed the realm of specialists. OBJECTIVE: To determine whether there were differences in patient characteristics, procedure complexity, and clinical indications when gastrointestinal endoscopic procedures were provided by generalists versus specialists. DESIGN: Retrospective cohort study. PATIENTS: A random 5% sample of aged Medicare beneficiaries who underwent rigid and flexible sigmoidoscopy, colonoscopy, and esophagogastroduodenoscopy (EGD) performed by specialists (gastroenterologists, general surgeons, and colorectal surgeons) or generalists (general practitioners, family practitioners, and general internists). MEASUREMENTS: Characteristics of patients, indications for the procedure, procedural complexity, and place of service were compared between generalists and specialists using descriptive statistics and logistic regression. MAIN RESULTS: Our sample population had 167,347 gastrointestinal endoscopies. Generalists performed 7.7% of the 57, 221 colonoscopies, 8.7% of the 62,469 EGDs, 42.7% of the 38,261 flexible sigmoidoscopies, and 35.2% of the 9,396 rigid sigmoidoscopies. Age and gender of patients were similar between generalists and specialists, but white patients were more likely to receive complex endoscopy from specialists. After adjusting for patient differences in age, race, and gender, generalists were more likely to have provided a simple diagnostic procedure (odds ratio [OR] 4.2; 95% confidence interval [95% CI] 4.0, 4.4), perform the procedure for examination and screening purposes (OR 4.9; 95% CI, 4. 3 to 5.6), and provide these procedures in rural areas (OR 1.5; 95% CI 1.4 to 1.6). CONCLUSIONS: Although generalists perform the full spectrum of gastrointestinal endoscopies, their procedures are often of lower complexity and less likely to have been performed for investigating severe morbidities.

Aged↗